| Office/Outpatient Care | C1 | C2 | C3 |
|---|---|---|---|
| Doctor’s Office Visits | |||
| Primary and OB/GYN Care | $10 | $20 | $30 |
| Specialist | $20 | $30 | $40 |
| Physical/Occupational Therapy | |||
| (30 visits per cal. year*) | $20 | $30 | $40 |
| Spinal Manipulations and Speech Therapy | |||
| (20 visits each per cal. year*) | $20 | $30 | $40 |
| Cardiac and Pulmonary Rehabilitation | |||
| (36 sessions each per cal year*) | $20 | $30 | $40 |
| X-Ray/Radiology/Diagnostics | |||
| Routine Radiology | $20 | $30 | $40 |
| MRI/MRA, CT Scans, PET Scans** | $40 | $60 | $80 |
| Injectable Medications | |||
| Standard Injectables | $0 | $0 | $0 |
| Biotech/Specialty Injectables** | $50 | $75 | $100 |
| Lab/Pathology | |||
| Copayment | $0 | $0 | $0 |
Coinsurance is based upon plan allowance and reflects amount paid by the plan.
* For AmeriHealth PPO and POS, combined in/out-of-network maximum.
** Preauthorization required for certain services.